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Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach. In this 6-part series, each Thursday, I’ll be sharing my most recent documentation tips.

By Timothy N. Brundage, M.D., CCDs

1. Dementia

It is important when documenting dementia to state whether the mental status is consistent with the patient’s baseline or if it is an acute condition:

• Acute Confusion or Acute Delirium on Chronic Dementia

• Dementia with Behavioral Disturbance

• Sundowning linked with Dementia

• Are there changes in a patient’s mental status at night?

• Metabolic Encephalopathy

• Are the changes in mental status worsened by infection?

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine